07 July 2014

Every ER has its call roster, that sacred list of oracles, laying out who we can call when our patients need some service that we cannot provide. If I need a cardiologist, or a neurosurgeon or even a dermatologist for some acute emergency condition, all I need to do is ring up the operator and tell them, “This is the ER doc, I need [insert name of specialty here].” And like magic, ten minutes later, I’m talking to the local expert in whatever the patient has.

Fun fact: in the last month, I have consulted both physiatry and rheumatology from the ER.

So I was a little surprised recently when I had a patient with a nine-millimeter proximal infected ureteral stone and I called the operator to get me urology, only to be told, “There’s nobody on call for urology.” Huh? I pulled the call roster from the wall and scanned it:

Wow. That’s a lot of specialties that we don’t have access to. For the record, we are not some little 40-bed rural hospital. We are a 100,000 visit facility that styles itself a “regional medical center” and accepts transfers from a large catchment area. And evidently there are multiple services we no longer offer, at least not in the evening and at other inconvenient times.

Why is this? Because these local specialists have decided, as individual groups, that ER work is taxing, difficult, low-paying and high-risk. (Tell me about it.) And one by one, they have decided to quit. They just said, “Nope, not covering the ER any more.” And our hospital is not the only one facing this problem. It is, in fact, probably the biggest challenge facing emergency medicine nationwide.

Now I get it. I die a little inside when I have to call in a board-certified urologist at 0300 to put in a foley on some poor 87-year-old in urinary retention, after all my nurses and I fail to get it in. I really hate inconveniencing them, especially when it’s something that I maybe should have been able to handle myself. But that’s the life of an ER doc and I am pretty inured to it by this time. (Maybe I’m all the way dead inside?)

The cardiologist writing that post painted a beautiful picture of how much call sucks, and I get it. I know the absence of call played into my decision to pursue Emergency Medicine as a career. But the question posed, in the context of the current situation, feels almost like blackmail: “Pay me or I’m gone, too.”

The history here is that being on call has pretty much always been a service that is part of the practice of medicine. No matter your specialty, if your patient got sick at night, you would be called in to deal with it. As the number of patients without established doctors grew, most hospitals had “no-doc” coverage rotating for unassigned patients. When you are on call, you don’t get paid for phone calls, but you do get paid if you have to come in and see or admit a patient (presuming they have insurance). In the old days call may have been a practice-growing revenue stream, but for a long time now it’s been a poorly-reimbursed time suck for most specialists.

A growing trend we are seeing nationally is for specialists to demand — and receive — reimbursement from the hospital just to be on call. Our hospital being a skinflint catholic shop responsible steward of resources told the specialists to pound sand, which led to their absenting themselves from the medical staff and call roster. But many hospitals, especially those in highly competitive markets, have started to pony up and pay docs to take call.

The math of this is really challenging. Once you are paying one group to be on call, it’s hard to justify not paying all of them. The most demanding, in my understanding, have been ENT, Hand, Neurosurgery, Optho, Plastics and Urology. The going rate seems to be about $1,000 per night, though YMMV. Ironically, these are among the least-consulted and highest-paying surgical subspecialties, which further creates an unseemly impression of physician greed. But if you meet their extortionate demands, that winds up costing the hospital $6,000 a day, 365 days a year, or about $2.2 million annually, assuming all the other specialists don’t pile on with their own demands. That’s for nothing, mind you: for being “available” without doing any work. No calls? You still bank nearly as much as I did for a busy shift of seeing patients.

And there is a tendency to see the hospital as the font of endless dollars, but hospitals are in rough shape. Their typical profit margin is in the 2-4% range, frequently dropping to zero or negative when the economy dips a bit, and under relentless pressure from medicare and insurers to accept lower reimbursements. While it’s tempting to look at the gross revenue and assume that of that $50-100 million, "surely the hospital can afford to pay to keep me on call,” in reality that is not the case.

The grim reality is this: we pay more than any other society for health care (and get less for it). There is no new money coming into the system; quite the opposite. When specialists demand extra money for a service that they have previously provided not for free but based on only professional reimbursement, that’s going to pull resources from somewhere else. Maybe it’ll be fewer ER nurses. Maybe it’ll be fewer staffed inpatient beds. It’s going to come out of the budget somewhere.

Which is why I am kind of glad our facility held firm in the face of the extortion of the surgical specialists. These guys all make ~$300K a year. I feel that if I (also well paid) have to see folks at 3am as part of my gig, they should too, and not command some premium for the service.

Am I bitter? Yes, a little. But much of that comes from the fact that I see the consequences of the specialists who opt out of call. I feel like they are still really well paid and are shirking their duty to the community and to the patients. That patient with the kidney stone? I had to transfer him out of our gleaming $500 million hospital to the county facility where a resident could take care of him. His care suffered because of the greed and entitlement of the local specialists; this wasn’t the first or last time I will encounter this problem. I don’t like seeing patients used as pawns, and I get a little enraged when local doctors jeopardize patient care over economic concerns. As I see more and more physician practices being bought by hospitals, in part to secure their call networks, I see these guys digging their own graves.

So, no, I don't favor paying specialists for being on call. Suck it up, guys, and do the right thing for your patients. Structure your practices to make call suck a little less, maybe. I empathize. When I'm sitting in a mostly empty ER at 4AM, I'm not getting paid either. But overall, we both make enough to have pretty good lives and still not opt out of caring for those who are unlucky enough to get sick at inconvenient times.

The clock-punching shift-worker wags a finger at specialists who make a calculated decision to control their lives and save their elective practice and perhaps their marriage and family. Specialists who, when they take on a patient, are responsible for them on an ongoing basis. Something that the clock-punching shift-worker knows nothing about. Once he punches out, that patient is never his responsibility again, unless he happens to show up at his next shift. The clock-punching shift-worker will never have a clinic day or elective OR day destroyed by an emergency, delaying the care of multiple patients. "Structure your practices to make call suck a little less, maybe", he says. Newsflash, clock-puncher- THERE'S NOT ENOUGH OF US. Additionally, most communities can't support a practice of 6 or more specialists that would make call frequency bearable and allow the on-call guy not to do elective work. Here's an idea- how about the hospitals hire their own specialists for call purposes? They have tried but are unsuccessful because THERE'S NOT ENOUGH OF US. So, don't even try with the "do the right thing" schtick. The dedication of the specialists you so freely denigrate puts your clock-punching, shift-working butt to shame.

Shiftworker??its because of people like him that your mom and dad gets proper Care for for a wide variety if acute conditions at odd timings while ur halfway across the country ..it takes guts to fight from the frontlines of medicine ..not something the slow paced schmucks will understand

A bit late to this discussion, but this is important.Over a 2+ decade career as a physician and surgeon, I have seen both sides of this story. No other profession allows itself to be abused in this way- obligated to be available on a 24 hour basis, held responsible for outcomes that are only partially under our control. Subject to retrospective review by well-paid critics who evaluate our work, work that we may do at 2 a.m. under severe stress, in chaotic ERs or ORs, with inadequate information. Their evaluations occur at 2 p.m. in the comfort of their carpeted offices.Why do we do it? Originally, we did it because we knew that if we did not do it, people would die, people who with our help are alive and functional. Not all of them, mind you, but enough to make it worthwhile. We did the best we could with what we had to work with. It was often but not always successful. Our non-physician fellow citizens understood that, appreciated and respected our work, and allowed us to go about our business. We often but not always got paid, and we continued to do it because we though t it was important. We had meaningful, sometimes brutal M&M conferences, to confront our mistakes, and improve our work. Now we have Quality Improvement Nurses who screen our charts for evidence of malfeasance.What happened then was it was noticed that 16% of the economy was running on its own. Can’t have that. Now every aspect of medicine is supervised, regulated, overseen by a vast array of governmental and quasi-governmental (think JCAHO and Blue Cross) bureaucracies and rent-seekers that decide who we will care for, when we will care for them, how etc., where etc., and what our payment will be. We are told that many things that are out of our control are hereafter deemed “NEVER” events, so if they occur, we have screwed up by definition. We are now “Providers” of “Healthcare.”So be it. You have taken away our ability to self-regulate. We will work under your regulations. We will work just so much, and that is it. We no longer work for the benefit of the patient. We work to satisfy the “indicators.” Did my patient get a DVT? In the old days, I felt terrible about that. Now, all I care about is if I ordered the correct protocol of DVT preventive measures as mandated by CMS. If I did, I’m untouchable. What, the client is in the ICU on a ventilator??? Not my problem, I ordered the right stuff. You can’t hurt me. Maybe it’s the nurse’s fault if the SCDs were not applied properly, or the heparin dose was delayed. Go bother someone else.I long ago gave up my private practice. I no longer take ER call. I am a shift worker. Once the clock strikes 7, it’s not my problem. I make less money, but I sleep at night. You see, there is nothing more rewarding than taking charge of a desperately ill patient, and navigating through the shoals of disaster to guide him through to recovery. There is nothing less rewarding than meeting indicators, satisfying SCIP “guidelines,” and being a “provider” of “healthcare,” avoiding Never events.It’s now all dollars and cents, meeting your numbers, avoiding having your charts “fall out” during Quality Improvement review. If a hospital employee truly screws up and actually threatens the well-being of our patients, we hold our tongues, lest we be deemed “disruptive.”And that’s why you have trouble with your call schedule.

Needless to say, I have this problem also -- we all do. On my last shift, I had a bad hand abscess. Local ortho and three transfer centers (including two large trauma centers) all refused the patient. I was getting set up to open the hand and semi-drain it myself to buy time -- a cowboy move, admittedly, but what could I do? -- when the ortho on call, thankfully, decided their doing it in the OR was at least better than me doing it in the ED.

I see a number of factors intersecting to create this problem:

1. Subspecialization. The scope that specialist are willing to operate across narrows further and further as people specialize and do fellowships in things every surgeon (or what have you) used to be expected to do. I don't blame the consultants (mostly.) Once a specialist exists you're judged by what they would have done if they'd been there or you'd sent the patient to them; that logic drives a lot of EM consultations and by the same token, can drive ortho to refuse to treat hands or GI to refuse to see a kid.

2. EM patients suck. Let's face it, folks, they do. When I call a consultant, what they here is "Hey, I've got a medically complicated, likely noncompliant abuser of several substances with no insurance and who hasn't paid a medical bill since 1963. Can you come in and take them off my hands?"

3. Ongoing responsibility. The one part of armydocs' bile-soaked excreta I agree with is this: It must truly suck to be responsible for the aforementioned ED patient on an ongoing basis because you did a procedure on them. Maybe that convention needs to change, and we need to collectively agree that an ED consult/procedure does not mean you "own" that patient beyond, say, two or three follow up visits.

4. Technology. Surgical and many medical specialists used to need hospitals to ply their trade. That leverage is disappearing with private surgery centers, outpatient labs and imaging, and the ability to do more and more from the office.

I don't have a solution, but I see it as a mixture of carrots (legal protections, limits to ongoing responsibility, expanding Medicaid and other insurance to ensure they get something for their time) and sticks (we can't rely on a tradition of specialists stepping up and taking responsibility for these patient, so we need some kind of requirement -- no doing colonoscopies all day for private patients and ignoring the GI bleed two miles away.)

Tracker- I’m not sure what your point is. You provide 4 additional examples to the ones that I posted explaining why specialists are reluctant to see ER patients. All of them are valid. Your response to my post above can best be described as lamesnark. We don’t object to being called Providers, we object to being treated as Providers. You object to us then acting like Providers. You can’t have it both ways.

I infer that you are an Emergency Physician. Undoubtedly you are aware of surgeons’ responsibility to provide ongoing care to our patients on a 24 hour basis, but some of our “civilian” readers may not be. The patients that you describe as “suck” often really do- they are often drug addicts, alcoholics, criminals, out of control obese and/or diabetic and/or hypertensive, and yes, often have no means or intention of paying a dime for their care. Your responsibility as ER doc ends when they are discharged from the ER or accepted by another physician. The accepting physician is responsible for that patient until the problem is resolved. The orthopedist on-call who drained that hand abscess is now obligated to follow that abscess until it is healed, and for a year (typically) afterward. No matter how many times he shows up in your ER at 2 a.m. with a real or imagined problem with his hand, the orthopod has to evaluate and treat the patient in a timely manner. You will have to see him also, if he happens to show up during your shift, but otherwise it will be another Emergency physician who will be relieved to see in the record that the patient is established with Dr. Ortho, and Dr. Ortho is obligated to see him, no matter what.

I have worked collaboratively with dozens of Emergency Physicians during my career. I have had an excellent working relationship with all of them- I recall zero events where the patient’s best interest was not served. Occasionally, the ER doc calls just for advice or to get approval to send the patient to my office the next day, but I overrule him and say that I need to see or admit the patient now. Emergency physicians know what a burden call is to docs, and call reluctantly, and I responded appropriately until the burden became unreasonable for me, and I quit my on-call job. Now there is one fewer person for them to call in my community. Yes, it sucks to be an ER doc who can’t find a specialist to take over his problem patient. Emergency physicians are not the cause of the problem. The cause of the problem is the actions of the lawyers, legislators, regulators, and administrators who have created the world that we all have to live in. Surgeons as a group are not organized enough to march in the streets, form effective lobbying organizations, or otherwise raise a ruckus. We just decide we have had enough, and stop showing up at 2 a.m. to Provide to the sucky patients. They are getting what they asked for, good and hard. I suspect that it will take some senator’s daughter dying for lack of an available specialist in the middle of the night before anyone important starts paying attention. That will be a tragedy, one of their own making.

Hey Shadowfax, lets get the facts straight. Most, if not all, ER docs get paid regardless of the # of patients they see. Second, your a SHIFT worker! Which means when your off your completely off. How would you like to be called on your off time to place a foley at 3 AM? The specialists you talk about work daily, do night calls and then go back to a full day of work the next day...about 36 hrs straight, so forgive us if we would like to actually get some sleep so we can function properly. Your argument that we should continue to do this b/c this is the way it's been done for years is IDIOTIC!! Your grandstanding make get you points with the general public but anyone in the medical field with sense will shake their head at you. I have a suggestion. Next time you work in the ER let your hospital know that you would like to do a double shift but they only have to pay for 1 shift. You need to understand what the specialist go through before you grandstand against it.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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